Diving into Academic Hyperbaric Medicine

Session 142

What inspired Dr. Anthony Medak to dive into the world of academic hyperbaric medicine? What’s it like inside of a hyperbaric chamber? He has been out of training now for 13 years as an emergency medicine undersea and hyperbaric medicine trained specialist.

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[01:49] Interest in Emergency Medicine and Hyperbaric Medicine

Anthony didn’t get a lot of exposure to it at his medical school. He went to medical school in San Francisco and there actually was no emergency medicine residency at that time. It wasn’t a required clerkship through third year.

So it wasn’t until towards the end of third year when some friends told him that that was something they were considering that he decided he should try to put it on his radar. So he tried to set up an elective as soon as he could in fourth year.

And when he did it, he just really felt a connection with the people in the department. And that was the most important thing for him was just the energy of the people in the emergency department. It was a visceral feeling that he belonged.

Previous to that, he was still pretty drawn to just the idea of acutely ill patients. He didn’t initially think he was very much enamored by outpatient medicine. So he was considering other things like being a hospitalist. On the inpatient side of things, that was the area that really captured his interest. He also considered working in a critical care setting with an acutely ill inpatient kind of setting.

Hyperbaric medicine is not a very common specialty. Anthony did residency at Highland Hospital in emergency medicine, and it’s a four-year program. He pretty much realized early on in residency that he’d like to do an academic career.

What he was really interested in was ultrasound. Growing up in Southern California, he also has a passion for scuba diving, snorkeling and basically, maritime medicine and undersea medicine.

So he decided to do an elective at UC San Diego while he was a fourth year resident to try to figure out what niche he would want. And he did an elective in hyperbaric medicine at UC San Diego for the better part of a month. And he loved it.

Anthony applied for fellowships both in emergency ultrasound as well as in hyperbaric medicine. Ultimately, after interviewing and consulting with his wife and everything, he decided to do a fellowship in hyperbaric medicine at UC San Diego.

So he thought of blending personal interests, which is the physiology of diving and the fact that he had a passion for scuba diving. Plus, he wanted to have an area of specialty that allowed him to get into the career he wanted ultimately, which was academic emergency medicine.

[05:05] What is Hyperbaric Medicine?

If you look through an emergency medicine textbook the hyperbaric medicine chapter will be towards the back and will be rather brief. It’s not an area of focus of a core emergency medicine curriculum although it’s part of it.

Anthony thought that hyperbaric medicine is just not a very big part, at least in most residences. His thought back then when he was still naive was that hyperbaric medicine was basically for sick scuba divers. It deals with people that get bends or what they call decompression sickness. Or patients that get arterial gas embolism from various types of pulmonary barotrauma in the setting of breathing compressed gas. And that they’re treating acute sick people that are still dripping wet, wearing their fins and their neoprene wetsuit, etc. In fact, that is certainly a part of hyperbaric medicine.

There’s another area in hyperbaric medicine that they do on a day to day basis and that is running chambers five to seven days a week. They’ll encounter divers around a couple of times per month. The other 20 plus days of the month, they’re treating patients with chronic refractory osteomyelitis.

They’re treating cancer survivors that have just wounds that won’t heal from the radiation therapy they’ve received sometimes decades ago. They also deal with plastic surgery cases such as when someone has some type of facial flap or breast reconstruction etc. And that plastic surgery flap becomes very tenuous and is in danger of essentially necrosis and sloughing off. So the surgeons will call them.

They have protocols to put these patients in the hyperbaric chamber to try to augment wound healing, and help preserve some of these at-risk tissues. And so, on the day to day basis, they do much more clinical hyperbaric medicine than they do undersea/diving medicine.

But the cool thing is it encompasses both. In fact, their international organization changed its name a number of years ago to the Undersea and Hyperbaric Medical Society. Decades ago, it was only the folks that were into the undersea diving medicine. And there was a whole different cadre of people that were into the clinical hyperbarics.

Ultimately, they formed one society that addresses the interests of both of those groups of providers. And so on a daily basis, Anthony does mainly the clinical hyperbaric medicine but they’re available 24/7 for diving emergencies all year long.

[08:00] Chamber Categories

Monoplace Hyperbaric Chambers

A type of chamber that accommodates a single individual is called a monoplace hyperbaric chamber. So it’s basically one person that lays semi recumbent in a 36 to 42 inch acrylic tube.

They’re in there by themselves. There’s a chamber operator that has the controls and everything outside of the chamber. And since it’s a clear acrylic tube, there are TV monitors etc. so that patients can kind of watch a movie or nap or they can bring a book in with them and they can read.

Essentially, you can’t really bring any electronics in there. So you can’t bring your tablet computer, you can’t bring your iPhone, your Apple Watch, etc. Any of those things could potentially be damaged from the high pressure.

And because the chamber is in a high pressure, high oxygen environment, all you need is an ignition source and unfortunately, you have an explosion. So they’re very vigilant about what goes in the chamber.

Specifically, they don’t allow any type of synthetic fibers in terms of clothing. Patients will check in and put on cotton scrubs and then they can go in with some reading material, but no watches, no hearing aids, no electronic devices in terms of any hyperbaric chamber, and stepping back as to what you alluded to what they look like etc.

At UC San Diego, they have what’s called a multiplace hyperbaric chamber that was built decades ago. It kind of resembles a giant tube, about six feet across and 21 feet long. It’s made of steel, not acrylic.

With these types of multiplex chambers, multiple patients and a staff member would go inside at one time. The chamber can treat three to six patients at a time with each treatment, which they often just refer to as a dive.

With each dive, they have multiple patients and a staff member in their particular facility. But many facilities will use these monoplace chambers where it’s one patient and no staff member and it’ll just look like an acrylic tube.

[11:24] Can You Practice It in the Middle of the Country?

As he previously mentioned, most hyperbaric medicine practices really don’t involve divers at all. They’re taking care of people with diabetes, peripheral arterial disease, as well as cancer survivors or those still battling various head and neck cancers, etc. And those types of individuals live everywhere. They live everywhere throughout the country and everywhere throughout the world.

There are patients who go scuba diving and then fly home the same day. So you still might see those patients. Somebody can be scuba diving in the Bahamas within just less than 24 hours and certainly come right back. Therefore, as a hyperbaric medicine specialist, you can be based in the middle of the country.

Oftentimes, if people fly after diving, they can get symptoms. And so when they land home in Idaho or wherever they may live, that’s when they may come seek your expertise because he didn’t have symptoms before but he took a flight and now he does.

[13:24] Traits that Lead to Being a Good Undersea and Hyperbaric Medicine Physician

You have to be able to think on your feet. For example, for anesthesiologists, oftentimes when things are going according to plan, it can be fairly stable and chill and not very stressful because you’ve done this before. You know how to manage the airway or how to take care of things that you anticipate.

But when stuff starts to go sideways in the operating room, that’s when an anesthesiologist can really show their colors and show what they’re capable of doing. And they’re expert at that.

And hyperbaric medicine is kind of the same way when everything’s going smooth. People in the chamber are coming and going. They’re not having any adverse effect, etc. It can be a good time just to get caught up on other stuff. Or see wound care of patients simultaneously while the chamber is operating with their hyperbaric patients because they have a wound center as well.

But occasionally, things could go wrong and people can have seizures in the chamber. People become hypoglycemic in the chamber.

They take pride in the fact that their chamber is a 24/7 operation. They deal with and will accept critically ill patients on drips, on a ventilator, etc. Those types of patients are by definition unstable, and they can often become more unstable in the chamber.

So you really have to have your wits about you. Particularly, if you don’t exclude critically ill patients, which some chambers and some facilities do just because they just don’t have the staff and the training to deal with those patients. But at their center, they take all comers.

So you have to be able to think on your feet, and very quickly go from everything’s calm, smooth to, “oh, no there’s something going on” and you’re expected to take care of it.

[15:25] Is It Procedure-Heavy?

In terms of the hyperbaric piece, it’s not very procedure heavy at all.

Many people that do hyperbaric medicine also do wound care. A lot of what they do in hyperbaric medicine is they treat patients that have refractory non healing wounds for months, sometimes years. And oftentimes, they can get those patients to heal.

Hence, they are often doing procedures related to those wounds. In other words, grafting those wounds, applying biosynthetic materials to try to help stimulate wound healing, doing surgical wound treatments in the office, etc.

There’s not a lot of procedures other than occasionally they will be expected to do something called myringotomy.

When you put someone in a hyperbaric chamber of any type, and you pressurize it to somewhere between usually 45 feet of seawater or 60 feet of seawater, there’s going to be change in pressure. This can lead to barotrauma to the tympanic membrane.

And if you have someone that is basically obtunded, unconscious or ventilated, they’re not going to be able to valsalva and clear their ears and calibrate that middle ear pressure. As a result, it can cause antigenic barotrauma to the ears.

To mitigate that risk, some centers will advocate for doing therapeutic myringotomies before you put someone in the chamber.

You anesthetize the area and then make a small perforation in an anatomically safe area so that the pressure can then collaborate on its own. Then that small opening will heal spontaneously in the coming weeks. So that’s the procedure they do, but Anthony admits they don’t do it frequently.

And then of course, if someone decompensates while in the chamber with all these changes in pressure, the other thing they always worry about is barotrauma, specifically pulmonary barotrauma, specifically pneumothorax.

So someone who develops pneumothorax, or has a pneumothorax in the chamber then the physician would be expected to pressurize and be locked in the chamber. It’s pressurized to the same treatment pressure that the patient is in, and then go in there and put in a chest tube for example. It doesn’t happen often but it definitely has to be within your skill set if you’re going to be supervising hyperbaric treatments.

[18:42] The Training Path

Hyperbaric medicine can come from many different specialties. At their institution, essentially all of them are full time emergency medicine physicians, and they all do anywhere from two or three or up to seven or eight weeks of hyperbaric medicine spread throughout the academic year.

All of their faculty are trained. This year, they have two emergency medicine trained physicians and one family medicine trained physician. And for the first time, they have one physician, one fellow that trained as a pathologist, and is doing hyperbaric medicine.

There is a board certification exam that one takes at the end. And then your research every 10 years. As alluded to earlier in their conversation, it is definitely not a super common path that is taken.

However, there’s not that many fellowship training programs, just maybe six or seven in the country. And so each of those might have anywhere between one to two or four spots. So Anthony thinks it’s moderately competitive from that standpoint because there’s not a ton of spots.

[21:07] Overcoming Negative Bias Against DOs

From the perspective of hyperbaric medicine, Anthony doesn’t think there is any bias against DOs.

[31:43] What He Wished He Knew that He Knows Now

Before Anthony came down for his elective, he was expecting to just do a lot more of the diving medicine piece. He didn’t realize that there was so much hyperbaric medicine that was separate from the diving piece.

That being said, he wished he knew more that a lot of hyperbaric medicine is not necessarily going to be always acutely ill.

Now that he’s in his mid 40s, he likes the continuity of care and the different pace and what he does on a day to day basis in the emergency department. He finds that it really complements his different skill sets.

His practice apparently evolved really nicely into his career as he moved into the mid phase career of his practice.

[23:20] Message to Future Primary Care Doctors

Since the specialty is not integrated into any residency program, internal medicine physicians or surgeons don’t really know a lot about what they do. So they’re kind of a black box.

And if the hyperbaric program is not very prominent in a particular facility or community where one practices in primary care, you might not even know there’s a hyperbaric chamber right down the street.

Anthony encourages future primary care providers to know that they do a lot of stuff with non healing wounds. And not all wounds need to be treated in a hyperbaric chamber. But most hyperbaric physicians have training in wound care, and they have the time and the expertise to kind of help with those things. Particularly with diabetics, they can really add a lot to the care.

He then encourages primary care physicians that if they have diabetic patients that are having issues with neuropathy and wounds that aren’t healing, consider hyperbaric therapy. And as a hyperbaric physician, it’s their job to determine if the risks and benefits are ultimately in the patient’s favor.

When the patient could potentially be a candidate, that’s when you put in a referral. They can do a full evaluation to decide this patient is a candidate or this patient’s not a candidate and they can try to help in that regard.

[25:10] Insurance Companies vs Hyperbaric Medicine

As mentioned above, there are two broad categories of chambers, those that accommodate one individual and those that accommodate multiple individuals. There are also different types of hyperbaric centers. Theirs is literally in the basement of a tertiary referral academic University Hospital. And there are also centers out there that are “freestanding.”

Some of the freestanding centers will abide by different rules as opposed to only dealing with indications and taking patients. There is some semblance of medical evidence and literature to support using hyperbarics, therefore applying for authorization and whatnot through insurers.

Some freestanding centers don’t deal with insurance at all. They will just allow patients that have the resources to pay directly for the hyperbaric treatment, whether or not an insurer will cover it becomes moot.

Because if one has the resources, basically a physician can put somebody in the chamber and treat them whether or not there’s any scientific evidence. They don’t have to worry about approval from any insurance. So it varies.

Hyperbaric centers are very vigilant and they only treat the indications in which there is a body of literature to support it. And most reputable or all reputable hyperbaric centers out there are going to play by that same rulebook.

The Undersea and Hyperbaric Medical Society publishes a literature review of all the approved indications every three or four years. Its most recent edition just came out last year with basically 13 approved indications. They run the gamut from the bends, decompression sickness, to radiation injury – from cancer to sudden sensorineural hearing loss, central retinal artery occlusion, carbon monoxide poisoning and on and on.

If they stick to those approved indications, and basically rely upon the existing literature and your documentation supports that, in general, the insurers are amenable to it.

But each particular third-party insurance company has its own set of rules and so you have to have good administrative support to know which indication will be approved and perhaps which won’t.

[27:53] The Most and Least Liked Things

Anthony is an emergency physician on a day-to-day basis. He deals with emergency medicine type of stuff where people are super sick, and you have to worry about managing airways. And it’s very, very stressful as it uses a particular skill set.

On the other hand, he likes working in the hyperbaric chamber because it has a different pace. He likes the ability to see patients come and go day after day, week after week, and see them progress and get better. That’s not generally something they see in the emergency department.

Moreover, Anthony likes the continuity of care. They get to become experts in an area of folks with diving and undersea medicine.

He has also grown to enjoy doing wound care and helping people avoid amputations and into limb salvage, which is a big part of what they do in the clinical hyperbaric world.

On the flip side, what he likes the least is sometimes the charting burden can be brutal. And although in emergency medicine he doesn’t really worry as much about getting authorization and insurance issues, etc. that is more uniquely a problem.

On the hyperbaric medicine side of things, they may get a consultation, see a patient that they think they can actually really help. But for whatever reason, the patient’s insurance won’t authorize it.

Then they get in a real bind, where they want to offer a service, they think they can help the patient get better. But as much as they want to do it gratis, they just because of rules that go above and beyond him.

And so frustrations with insurance and getting authorization, which only seems to be getting worse, unfortunately, is a frustration that they have in the hyperbaric department.

[30:08] Major Changes Coming to the Field

They’re a part of a multicenter, randomized trial, looking at the efficacy of hyperbaric medicine for traumatic brain injury.

This is something he’s very excited to see moving forward over the next couple of years if that body of data will demonstrate evidence to support the use of hyperbaric for traumatic brain injury patients.

It would allow the field to grow because they’re not just primarily treating divers or diabetics, or patients that are suffering from or have battled cancers. Now you’re talking about adding a whole nother population of patients such as traumatic brain injury patients.

[31:39] Final Words of Wisdom

If he had to do it all over again, Anthony would have chosen the same field. Finally, his message to all premed students out there who might be interested in the specialty is to look this program up in your school.

See in your medical school catalog if they offer an elective. Their school actually offers an elective and they accept away students. They’re fourth year students that come and spend four weeks with them to do an elective in hyperbaric medicine. They get exposed to diving medicine, wound care, and running the chamber. And they really enjoy it.

Check with your home institution to see if perhaps you have a chamber. See if they offer a fourth-year elective that you can do during medical school because it’s a nice time. So it’s a good fourth year rotation. It’s fun, it’s something you likely might not be able to have the opportunity to do again moving forward.

And you just might be surprised how much you like it. Even if you decide you don’t want to do a whole nother year fellowship and you go on to become a general surgeon, an otolaryngologist, or a primary care physician. You’ll at least have some idea of which of your patients might benefit from being sent over to the hyperbaric department for a consultation. Maybe they can help you with some problem that you’re having difficulty with and a challenge with your patient and whatever practice you may ask.